The Costs of Clinical Education: The ‘Real World’ Mission

Mark DeRuiter

June 2017

It is always a pleasure to connect with program directors as they consider the ways clinical education fits within the larger structure of a department’s mission and vision. Working in an educational environment has a real “student first” thrust to it, and, it is one that we all understand. Often, figuring out how a clinic, patients, and funding coalesce to make for a meaningful and programmatic model becomes one of our greatest challenges. This is particularly true as university programs face financial pressures. Additionally, as programs consider the implementation of regulations for serving Medicare beneficiaries (or other payers), there is a shift to business practices versus “business as usual.”

This variety of factors creates a “push–pull” for faculty, clinicians, and administrators, and raises several questions: What is the mission of your clinical education program? Do our university clinics need to operate “like the real world”? Should they stand on their own financially? Or, do these clinics serve a different purpose? These broad questions usually lead us back to a simpler set of questions: What do we know today? What information do we need? What else should we be considering? Below you will see the conversation points I often have with colleagues as we sift through the push-pull of clinical education and determine the information required to inform the broader questions and considerations.

What Are Your Costs?

If you have aspirations for functioning similarly to the “real world,” keeping the clinic doors open has many different costs that contribute to the equation. You need to consider factors such as personnel, materials, ongoing expenses of technology, calibration, and the list goes on. When it comes to space and utilities in a university setting, the answer to this question can feel elusive. The larger the university, the more difficult it can be to chase down costs due to cost pooling (e.g., where heat, cooling, electricity, general upkeep and other utilities are bundled and billed to a department) and other factors. However, it is important to understand exactly what you are dealing with here. Are your costs similar to the competitive environment? Think of space alone—is your cost per square foot comparable to what an entrepreneurial clinician might pay in your community? If not, you need to have an open conversation with your university administration as to how your clinic is different from those in the community. Of concern to many program directors is, “What if my costs are so high that I have a problem that can’t be solved?” This is where you and your departmental administrative team need to wade into the information carefully and thoughtfully. Not having an answer can be troubling when you are pressed for this information from higher administration levels.

What Are Your Clients/Patients Paying For Your Services?

This question pops up from time-to-time with clinicians and program directors engaging or about to engage in worried conversations about “price-fixing” or discussions of “pricing from the hospital down the street.” Although price-fixing is beyond the scope of an article such as this one, there are resources available related to pricing. First, there is the published Medicare Fee Schedule. You can find this information through American Speech-Language-Hearing Association publications. With a little work, you will soon understand what the federal government defines as its “maximum” rate. This benchmark often is a great conversation starter. There also are contracted rates available to you, should you engage with other third-party payers. But, remember, your clinic fees should not just be in line with “what others will pay.” Your charges need to be in line with what it will take to keep your clinic doors open. Clarity about the costs of doing business is most critical!

What Are The Relevant Issues For Payers, Contracts And Educational Models?

This question has caused some of the largest challenges recently. Medicare Part B (outpatient) services require a personal-level of supervision. This means that the supervising clinician is in the room 100 percent of the time, directing the service to the Medicare beneficiary. Therefore, the days of having one clinician supervising four students concurrently are gone, if one or more of the patients served in the mix is a Medicare beneficiary. This requirement changes the model greatly—bringing it much closer to what we see in our community. In community settings, students are not on the front line of service provision for assessment and treatment; fully-credentialed clinicians provide the service. This is an important distinction between community-based services and services provided in many university clinics.

What About Student Tuition?

Take a look at graduate programs in our discipline and you will find that a substantial portion of a student’s tuition burden goes to clinical education. However, not all administrators feel that these funds “count.” I’d invite you to have a different conversation about that. How many other clinics external to universities have a student tuition funding stream? This is an apples-to-oranges conversation that is worthy of time and attention. CSD educational programs have a layered system where both our clients/patients and our students “pay.” We have obligations to serve all of them ethically and to the best of our ability.

Wrapping It Up

Finally, there is another important “real world” consideration as you think through the mission of the clinic in your educational program. Consider the odds of a speech-language clinic or audiology clinic surviving on its own in your community’s competitive environment. Is it possible? The answer may be less optimistic than you think, especially in an environment of contracted payment and narrow networks. “Real world” clinics are addressing the same cost, pricing, and contracting issues that CSD program directors should be considering as well.

This article originally appeared in the Access Academics and Research Newsletter